|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 68084-710-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
NDC 0406-0523-62
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]
|
Facility
|
OP
|
$2.16
|
|
|
Service Code
|
NDC 68308-480-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.62
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.84
|
| Rate for Payer: Dignity Health Senior |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Senior |
$0.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Vantage Medical Group Senior |
$1.84
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 68084-710-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.54
|
| Rate for Payer: Blue Shield of California Commercial |
$1.26
|
| Rate for Payer: Blue Shield of California EPN |
$1.01
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.75
|
| Rate for Payer: Dignity Health Senior |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Senior |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 68084-710-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]
|
Facility
|
OP
|
$3.16
|
|
|
Service Code
|
NDC 0406-0523-23
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.93
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.69
|
| Rate for Payer: Dignity Health Senior |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.69
|
| Rate for Payer: Vantage Medical Group Senior |
$2.69
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 53746-203-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0904-7093-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 42858-102-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 42858-102-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 53746-203-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0904-7093-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208667]
|
Facility
|
OP
|
$6.98
|
|
|
Service Code
|
NDC 59011-410-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.93 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4.26
|
| Rate for Payer: Blue Shield of California EPN |
$3.41
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.93
|
| Rate for Payer: Dignity Health Senior |
$5.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.32
|
| Rate for Payer: Heritage Provider Network Senior |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.89
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.79
|
| Rate for Payer: TriValley Medical Group Senior |
$2.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.93
|
| Rate for Payer: Vantage Medical Group Senior |
$5.93
|
|
|
OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208667]
|
Facility
|
IP
|
$6.98
|
|
|
Service Code
|
NDC 59011-410-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.24 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.73
|
| Rate for Payer: Heritage Provider Network Senior |
$4.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
|
|
OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208669]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 59011-420-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$9.75 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Cash Price |
$7.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.80
|
| Rate for Payer: Heritage Provider Network Senior |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
|
|
OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208669]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 59011-420-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$11.05 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.75
|
| Rate for Payer: Blue Shield of California Commercial |
$7.93
|
| Rate for Payer: Blue Shield of California EPN |
$6.34
|
| Rate for Payer: Cash Price |
$7.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.05
|
| Rate for Payer: Dignity Health Senior |
$11.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.05
|
| Rate for Payer: Heritage Provider Network Senior |
$8.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.10
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.20
|
| Rate for Payer: TriValley Medical Group Senior |
$5.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.05
|
| Rate for Payer: Vantage Medical Group Senior |
$11.05
|
|
|
OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208671]
|
Facility
|
OP
|
$22.26
|
|
|
Service Code
|
NDC 59011-440-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$18.92 |
| Rate for Payer: Adventist Health Commercial |
$4.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.70
|
| Rate for Payer: Blue Shield of California Commercial |
$13.58
|
| Rate for Payer: Blue Shield of California EPN |
$10.86
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.92
|
| Rate for Payer: Dignity Health Senior |
$18.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.78
|
| Rate for Payer: Heritage Provider Network Senior |
$13.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.58
|
| Rate for Payer: Multiplan Commercial |
$16.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.90
|
| Rate for Payer: TriValley Medical Group Senior |
$8.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.92
|
| Rate for Payer: Vantage Medical Group Senior |
$18.92
|
|
|
OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208671]
|
Facility
|
IP
|
$22.26
|
|
|
Service Code
|
NDC 59011-440-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$16.70 |
| Rate for Payer: Adventist Health Commercial |
$4.45
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.07
|
| Rate for Payer: Heritage Provider Network Senior |
$15.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.57
|
| Rate for Payer: Multiplan Commercial |
$16.70
|
|
|
OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208673]
|
Facility
|
IP
|
$38.86
|
|
|
Service Code
|
NDC 59011-480-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$29.14 |
| Rate for Payer: Adventist Health Commercial |
$7.77
|
| Rate for Payer: Cash Price |
$21.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.31
|
| Rate for Payer: Heritage Provider Network Senior |
$26.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.71
|
| Rate for Payer: Multiplan Commercial |
$29.14
|
|
|
OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208673]
|
Facility
|
OP
|
$38.86
|
|
|
Service Code
|
NDC 59011-480-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$33.03 |
| Rate for Payer: Adventist Health Commercial |
$7.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$20.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.14
|
| Rate for Payer: Blue Shield of California Commercial |
$23.70
|
| Rate for Payer: Blue Shield of California EPN |
$18.96
|
| Rate for Payer: Cash Price |
$21.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.03
|
| Rate for Payer: Dignity Health Senior |
$33.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.05
|
| Rate for Payer: Heritage Provider Network Senior |
$24.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27.20
|
| Rate for Payer: Multiplan Commercial |
$29.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.54
|
| Rate for Payer: TriValley Medical Group Senior |
$15.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.03
|
| Rate for Payer: Vantage Medical Group Senior |
$33.03
|
|
|
OXYMETAZOLINE 0.05 % NASAL MIST [114934]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 11523-1159-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Senior |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
OXYMETAZOLINE 0.05 % NASAL MIST [114934]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 0363-0308-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Senior |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
OXYMETAZOLINE 0.05 % NASAL MIST [114934]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 0363-0308-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
OXYMETAZOLINE 0.05 % NASAL MIST [114934]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 2390002325
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Senior |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
OXYMETAZOLINE 0.05 % NASAL MIST [114934]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 11523-1159-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
